Editor’s Note: This editorial is based on the Presidential Address given by Dr. Jurkovich at the 2012 annual meeting of the Western Surgical Association.
Regionalization of health care is part of the larger dynamic of change in medicine that includes an aging population, financing reform, and generational identity issues of physicians in training and future providers of care. Trauma systems provide a model for effective regionalized care, and in this context, I propose a network of national acute care surgery hospitals built on this model. But there are lessons that can be learned from 35 years of trauma systems development and implementation that can be applied to a network of national acute care surgery hospitals (J. Am. Coll. Surg. 2012;215:1-11).
The problem of lack of emergency surgical resources has been noted since the beginning of the 21st century, and has received considerable attention from a wide variety of public and private organizations and government agencies. A cover story of U.S. News and World Report in 2001 was entitled "Crisis in the ER." The influential Institute of Medicine (IOM) three-volume report in 2009 entitled "Future of Emergency Care" noted that hospital-based emergency care was as the breaking point, with overcrowding of emergency departments (ED), boarding of patients in the ED, with ambulance diversion and uncompensated care being the most pressing problems. The Robert Wood Johnson foundation report authored by Dr. Mitesh B. Rao and his colleagues in 2011 highlighted the shortage of surgeons who take emergency call and suggested that "three-quarters of the nations’ emergency departments do not have enough on-call coverage by surgical specialists to meet the demand for round-the-clock specialty care."
One of the key solutions suggested in the IOM report was to develop regionalized on-call specialty care services. The concept is that if hospitals cannot find willing (or able) surgical coverage for certain surgical urgencies or emergencies, then the patients should be sent to regionalized centers of care that can provide these services. The burden on the patient is significant: The patient may have to travel some distance to receive health care. The burden on the receiving hospital is also significant: The patients often are the most challenging and underfunded in medicine. The burden on the profession of surgery is also significant, if often overlooked: a further erosion of the perception of our profession from one concerned primarily with the sick and suffering and to a perception that specialty surgeons are more concerned about lifestyle and personal gain. Nonetheless, this does appear to be the best model for the future of surgical care. The purpose of regionalization of care is to consolidate complex and high-technology medicine into regional centers with adequate surgeons in all specialties, in the hope that this will ensure quality and cost-effective care. It is an opportunity for surgical leadership to become involved in this dramatic change in medicine.
Regionalization: The trauma system model
In 1976, the American College of Surgeons Committee on Trauma published the first version of "The optimal resources for a hospital." The eighth version will be released shortly. This document is the authoritative source on trauma center function. Initially developed to serve as a guideline for what resources were required for a hospital trauma center, a name change in 1990 to "Resources for Optimal Care of the Injured Patients" expanded the implications and reach of these guidelines (J. Trauma 1998;47(3 Suppl.):S1).
What makes trauma center care better? In a study of 31 academic Level 1 trauma centers, the higher volume trauma centers (more than 650 major trauma admissions per year) had improved outcomes, particularly for the sickest patients (JAMA 2001;285:1164-71).
Improved critical care also seems partially responsible for better outcomes at trauma centers. The ability of trauma centers to salvage patients with complications or severe shock and injury appears to be a defining characteristic of those centers with the better outcomes. In addition, trauma intensive care units that are "closed" and staffed by surgical critical care surgeons achieve the best results (J. Trauma 2011;70:575-82; Arch. Surg. 2003;138:47-51;discussion 51; J. Trauma 2006;60:773-83;discussion 783-4; Ann. Surg. 2006;244:545-54).
The reasons trauma centers have improved outcomes appears to be multifactorial, injury-pattern dependent, and not entirely understood. It appears it is not just the hospital designation that makes the difference, but the design and effectiveness of system integration that is equally important.
These examples emphasize the point that a series of activities and actions is required for regionalizing care, not simply forcing a specific population of patients into one hospital. The model trauma system plan written by the HRSA in 1992, with help from the ACS Committee on Trauma and CDC continues to serve as the benchmark for trauma system design (Health Resources and Services Administration. A 2002 national assessment of state trauma system development, emergency medical services resources, and disaster readiness for mass casualty events. Washington: U.S. Department of Health and Human Services, 2003). This plan is based on work and definitions first described by West et al., and modified by Bazzoli et al. (JAMA 1995;273:395-401; JAMA 1988;259:3597-600).